Doctors, welfare, and the deadly workhouse

The Beveridge Report, which led to the founding of the British welfare state, was published 70 years ago today, but the first attempt to design a modern 'scientific' welfare system for Britain is closer to 180 years old

The Beveridge Report, which led to the founding of the British welfare state, was published 70 years ago today, but the first attempt to design a modern "scientific" welfare system for Britain is closer to 180 years old. The result was the infamous Victorian workhouse, an institution that the editor of the medical journal the Lancet claimed could kill 145,000 people every year – and all because the government was ignoring medical and statistical evidence.

Britain has had a system of organised welfare for more than 400 years; from 1601 the Elizabethan Poor Law provided a functional framework for raising local taxes to help the local poor, until the Industrial revolution created cities too big and parishes too poor to be helped in this way. In 1832, after a period of serious social disturbance, the government set up the Royal Commission of Inquiry into the Operation of the Poor Laws, headed by lawyer Edwin Chadwick. Basing their evidence on a survey with only a 10% response rate, the commissioners recommended a series of reforms, which were made law in 1834 when the Poor Law Amendment Act was passed.

The commissioners particularly wanted to prevent abuse of the Poor Law system; they were worried that support for children would encourage poor women to behave "immorally", and that in an era of low wages a "life of idleness" on Poor Law relief might be more attractive than hard work to poor men. This was the reason for the harsh regime of the workhouse, which was designed around a principle known as 'less eligibility', in other words that life on welfare had to be made worse than life at work in the slums.

The commissioners recommended a shift from traditional 'out-relief' (clothes, food or other help provided direct to the poor) to institutional 'in-relief'. Families were separated, food and facilities kept basic, and arduous physical labour required of those who could manage it. Those too sick to work, or the very elderly, were to be housed in workhouse infirmaries (hospitals) – although few were built, and in many cases the 'infirmary' was simply a separate room in the workhouse. (There's much more detail about these institutions on the workhouses website run by Peter Higginbotham)

There were many moral objections to the workhouse system – but some of the loudest criticism was based on statistical and medical grounds. Thomas Wakley, one of the founders of the medical journal the Lancet, and its editor at the time, wrote in 1841 that the workhouses were the "antechambers of the grave" (Lancet, 1 May 1841 p193-196). He claimed that the gruel dietary, and the sheer mental depression of imprisonment and shame meant that inmates were vulnerable to diseases that the limited workhouse medical facilities then failed to treat effectively. This disease could leak out into the community, as "several epidemics appear to originate in the workhouses, as they did in the prisons of old".

Wakley wasn't alone – many doctors emphasised the role of poverty and want in the propagation of infectious diseases. Scottish physician William Pulteney Alison's survey of poverty and disease – Observations on the Management of the Poor in Scotland (1840) – also pointed to 'deficient nourishment, want of employment, and privations of all kinds, and the consequent mental depression' as being more likely to contribute to the spread of fever than 'any cause external to the human body itself'.

Such detailed and statistical studies of death in the workhouses and in the slums did not convince Chadwick, who had commissioned his own team of doctors to study the causes of disease among the poor, particularly epidemic diseases in towns and cities. The Report on the Sanitary Condition of the Labouring Population published in 1842 claimed that the dirt and filth of city living, plus the poor hygiene and lazy, immoral habits of the poor, were the causes of epidemic and contagious diseases. Hunger, poverty and mental depression were not the true problem – causes 'external to the human body' were what mattered. According to Chadwick:

the various forms of epidemic, endemic, and other disease [are] caused, or aggravated, or propagated chiefly amongst the labouring classes by atmospheric impurities produced by decomposing animal and vegetable substances, by damp and filth, and close and overcrowded dwellings

This interpretation, Chadwick's "sanitary principle" set the terms for future Victorian public health reforms – which would build great sewers, cleanse the slums, provide clean water to the poor, and regulate polluting industries. These are reforms we celebrate; yet the flip-side of Chadwick's understanding that dirt, and not misery or hunger, caused disease was the continuation of the workhouse system and its hard conditions.

Wakley's articles are very much of their time; he is interested in the particular political problems, the particular medical theories, and the specific statistical evidence of the 1830s and 40s. That said, it's still hard to read his passionate polemics without being reminded of more recent events – perhaps last week's report by the Care Quality Commission about the neglect of some vulnerable recipients of 'in-relief', or the campaigns by doctors and others against the new Work Capability Assessment system. Wakley's 1841 editorial finishes with this plea to doctors

We earnestly entreat the Medical Profession throughout the country to exert themselves to the uttermost at the present crisis. They may put a stop to the atrocities of the new Poor-law system. We address the Medical Profession on this subject, as a body of the most intelligent and benevolent men in the country; they know the poor; they have witnessed their sufferings. Let them, then, in the name of GOD, and of common humanity, with one voice, call upon the Legislature for deliverance from the fatal workhouse system: it is their office to stand between the destroyed and the destroyer.